Introduction

Acute compartment syndrome occurs when there is increased pressure within a closed fascial compartment, resulting in impaired local circulation. Acute compartment syndrome is considered a surgical emergency since without proper treatment it can lead to ischemia and eventually necrosis. Generally, acute compartment syndrome is considered a clinical diagnosis, however intracompartmental pressure (ICP) > 30 mmHg can be used as a threshold to aid in diagnosis. However, a single normal ICP reading does not exclude acute compartment syndrome.

Fascia is a thin, inelastic sheet of connective tissue that surrounds muscle compartments and limits the capacity for rapid expansion. In the leg, there are four muscle compartments: anterior, lateral, deep posterior, and superficial posterior. The anterior compartment of the leg is the most common location for compartment syndrome. This compartment contains the extensor muscles of the toes, the tibialis anterior muscle, the deep peroneal nerve, and the tibial artery.

Other locations in which acute compartment syndrome is seen include the forearm, thigh, buttock, shoulder, hand, and foot. It can also be seen in the abdomen, but that is reviewed in a separate article. [1][2][3][4][5]

Etiology

Acute compartment syndrome can occur with any condition that restricts the intracompartmental space or increases the fluid volume in the intracompartmental space. Acute compartment syndrome can occur without any precipitating trauma but typically occurs after a long bone fracture, with tibial fractures being the most common cause of the condition, followed by distal radius fractures. Seventy-five percent of cases of acute compartment syndrome are associated with fractures. After fractures, the most common cause of acute compartment syndrome is soft tissue injuries. Burns, vascular injuries, crush injuries, drug overdoses, reperfusion injuries, thrombosis, bleeding disorders, infections, improperly placed casts or splints, tight circumferential bandages, penetrating trauma, intense athletic activity, and poor positioning during surgery are some of the other causes of acute compartment syndrome.

In children, supracondylar fractures of the humerus and both ulnar and radial forearm fractures are associated with compartment syndrome. [6][7][8][9][5][10][5]

Epidemiology

The incidence of acute compartment syndrome is estimated to be 7.3 per 100,000 in males and 0.7 per 100,000 in females, with the majority of cases occuring after trauma. Tibial shaft fractures, the most common cause of acute compartment syndrome, are associated with a 1-10 percent incidence of acute compartment syndrome.

Acute compartment syndrome occurs more commonly in males younger than 35, which may be due to a larger relative intracompartmental muscle mass and increased likelihood of being involved in high energy trauma.

Patients with bleeding diathesis such as hemophilia are at greater risk for acute compartment syndrome. Cases of acute compartment syndrome have been reported without acute precipitating trauma in pediatric leukemia. [4][5][11][12][10]

Pathophysiology

Acute compartment syndrome occurs due to decreased intracompartmental space or increased intracompartmental fluid volume, because the surrounding fascia is inherently noncompliant. As the compartment pressure increases, hemodynamics are impaired. There is normally an equilibrium between venous outflow and arterial inflow. When there is an increase in compartmental pressure, there is a reduction in venous outflow. This causes venous pressure and thus venous capillary pressure to increase. If the intracompartmental pressure becomes greater than arterial pressure, a decrease in arterial inflow will also occur. The decrease of venous outflow and arterial inflow result in decreased oxygenation of tissues causing ischemia. If the deficit of oxygenation becomes great enough then, irreversible necrosis may occur.

The normal pressure within a compartment is less than 10 mmHg. If the intracompartmental pressure reaches 30 mmHg or greater, acute compartment syndrome is present. However, a single normal ICP reading does not exclude acute compartment syndrome; ICP should be monitored serially or continuously. [13][14][15]

History and Physical

Acute compartment syndrome typically occurs within a few hours of inciting trauma, however, it can present up to 48 hours after. The earliest objective physical finding is the tense, or "wood-like" feel of the involved compartment. Pain is typically severe, out of proportion to the injury. Early on, pain may only be present with passive stretching. However, this symptom may be absent in advanced acute compartment syndrome. In the initial stages, pain may be characterized as a burning sensation or as a deep ache of the involved compartment. Paresthesia, hypoesthesia, or poorly localized deep muscular pain may also be present.

Classically, the presentation of acute compartment syndrome has been remembered by "The Five P’s": pulselessness, paresthesia, poikilothermia, paralysis, and pallor.However, aside from paresthesia, which may occur earlier in the course of the condition, these are typically late findings. Beware that the presence or absence of a palpable arterial pulse may not accurately indicate relative tissue pressure or predict the risk for compartment syndrome. In some patients, a pulse is still present, even in a severely compromised extremity.

Physical exam should focus on the neurovascular territory of the involved compartment:

Although the clinical features discussed above can help identify compartment syndrome, they have limited sensitivity and specificity. Other factors, such as compartment pressures, can be helpful in making the diagnosis.

Due to the potential for rapid progression of compartment syndrome, clinicians should perform serial exams.

Evaluation

Radiographs should be obtained if a fracture is suspected

Measurement of intracompartmental pressure is not required but can aid in diagnosis if uncertainty exists. Compartment pressures are often measured with a manometer, a device that detects intracompartmental pressure by measuring the resistance that is present when a saline solution is injected into the compartment. Another method employs a slit catheter, whereby a catheter is placed within the compartment, and the pressure measured with an arterial line transducer. The slit catheter method is more accurate and allows for continuous monitoring. Its use is also recommended to measure all the surrounding compartments.

The normal pressure within the compartment is between 0 mmHg to 8 mmHg.

If rhabdomyolysis is being considered, renal function testing, urine myoglobin, and urinalysis should be tested.

If rhabdomyolysis is diagnosed, a chemistry panel is needed.

Preoperative studies should, at a minimum, include a complete blood count and coagulation studies. [16][17][18]

Treatment / Management

Immediate surgical consult

Provide supplemental oxygen.

Remove any restrictive casts, dressings or bandages to relieve pressure.

Keep the extremity at the level of the heart to prevent hypo-perfusion.

Prevent hypotension and provide blood pressure support in patients with hypotension.

If ICP greater than or equal to 30 mmHg or delta pressure less than or equal to 30mmHg, fasciotomy should be done.

For patients who do not meet diagnostic criteria for acute compartment syndrome but who are at high risk based on history and physical exam findings, or for patients with intracompartmental pressures between 15-20 mmHg, serial intracompartmental pressure measurements are recommended. Patients with ICPs between 20-30 mmHg should be admitted and the surgical team should be consulted. For patients with intracompartmental pressures greater than 30 mmHg or delta pressures less than 30 mmHg, surgical fasciotomy should be done.

Acute compartment syndrome is a surgical emergency, so prompt diagnosis and treatment are critical. Once the diagnosis is confirmed, immediate surgical fasciotomy is needed to reduce the intracompartmental pressure. The ideal timeframe for fasciotomy is within six hours of injury, and fasciotomy is not recommended after 36 hours following injury. When tissue pressure remains elevated for that amount of time, irreversible damage may occur, and fasciotomy may not be beneficial in this situation.

If necrosis occurs before fasciotomy is performed, there is a high likelihood of infection which may require amputation. If infection occurs, debridement is necessary to prevent the systemic spread or other complications.

After a fasciotomy is performed and swelling dissipates, a skin graft is commonly used for incision closure. Patients must be closely monitored for complications which include infection, acute renal failure, and rhabdomyolysis. [2][1][19]

Differential Diagnosis

Deep vein thrombosis

Cellulitis

Gas gangrene

Phlegmasia cerulean dolens

Rhabdomyolysis

Prognosis

The prognosis after treatment of compartment syndrome depends mainly on how quickly the condition is diagnosed and treated:

When fasciotomy is done within 6 hours, there is almost 100% recovery of limb function.

After 6 hours, there may be residual nerve damage. Data show that when the fasciotomy is done within 12 hours, only 2/3rd of patients have normal limb function.

In very delayed cases, the limb may require an amputation.

Outcomes for the posterior compartment syndrome of the leg are worse than outcomes for the anterior compartment of the leg, since it is difficult to perform inadequate decompression of the posterior compartment.

Complications

Postoperative and Rehabilitation Care

Physical therapy to regain function and strength and prevent contractures and stiffness.

Wound care and monitoring for any ischemia, infection, gangrene.

Antibiotics if infection if warranted

Pain medicine

The patient will need to learn how to use an ambulatory device like crutches until healing is complete.

An occupational therapy consult is recommended to help teach the patient how to perform daily living activities. [23][24][25]

Consultations

Orthopedic or surgical consultation

Infectious disease, if needed

Wound care, if needed

Physical therapy, if needed

Occupational therapy, if needed

Deterrence and Patient Education

Patients should be educated to seek care after traumatic injury or if they develop pain or swelling of an extremity.

Pearls and Other Issues

When applying plaster casts, especially following reduction, uni-valving or bi-valving can help to reduce the pressure by about 50%. Beware that once the initial swelling dissipates, the cast can become excessively loose, which can decrease the amount of reduction accomplished.

Enhancing Healthcare Team Outcomes

The management of acute compartment syndrome requires a well-integrated interprofessional team of healthcare professionals including nurses, laboratory technologists, pharmacists and multiple physicians in different specialties. Without proper management, acute compartment syndrome can lead to high morbidity and poor outcomes.

The nurses are usually the first health professional to see the patient, often in triage in the emergency department. The nurse must quickly access that the patient has signs and symptoms consistent with compartment syndrome and immediately involve the clinical team to further access the patient. The nurses will need to assist in monitoring the patient's vital signs, pain, and assist in getting the patient to the operating room where definitive treatment usually takes place. After the procedure, they will need ongoing evaluation as often a patient with compartment syndrome will have multiple other injuries that require attention as well as complications as a direct result of the compartment damage.

Pharmacist in the emergency department can assist in medication reconciliation as well as providing recommendations regarding pain management.

The nurse practitioner, physician assistant, and physicians often provide a role in coordinating the care, performing procedures, as well as education of the patient and family regarding the nature of the injuries.

After surgery, an interprofessional team that provides a holistic approach can help achieve the best possible outcomes for patients. This may include the surgery or orthopedics team, nurses, physical therapists, occupational therapists, pharmacists, and social workers. Due to the complexity of care required, the best outcomes will be achieved by the use of an interprofessional team. [Level V]

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Acute Compartment Syndrome - Questions

Take a quiz of the questions on this article.

A 12-year-old child has a fractured ulna and radius that is treated with open reduction and internal fixation. The surgeon is worried that the procedure was long but did not do a fasciotomy. What is the first sign of compartment syndrome?

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A 17-year-old patient presented with significant pain and numbness of the left lower leg one day after karate practice. He recalled a painful blow to the anterior tibial region during the practice, and the pain has gotten progressively worse with the development of swelling. Physical examination showed pain out of proportion when the left foot was passively stretched. Which of the following is true in the making of diagnosis for compartment syndrome for this patient?

Loss of distal pulses is not a reliable early predictor of compartment syndrome

The diagnosis of compartment syndrome is based on the finding of significant soft-tissue swelling

Elevated myoglobin level confirms the diagnosis of compartment syndrome due to soft tissue and muscle damages

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A patient was in the emergency department for a fracture of the distal radius and ulna. A circumferential cast was placed. The patient calls and complains of increasing pain and numbness. Which of the following is most appropriate for the management of this patient?

Arrange for an arterial Doppler of the deep venous system to detect thrombus

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A patient sustains a blow to the shin during karate class. He complains of pain and numbness of the foot and lateral lower leg. There is decreased strength noted for ankle eversion and dorsiflexion. The mid-calf measurement is 5 cm greater on the involved side. What is the most likely diagnosis?

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A patient suffered a severe inversion of the ankle and is unable to bear any weight on it. He is in excruciating pain. The lateral aspect of the leg is tense but the dorsalis pedis and posterior tibial artery pulses are palpable. What is the next step in his management?

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A 17-year-old female is in a motor vehicle accident. She complains of a deep and aching pain and a burning sensation in her left lower leg. A firmness of the anterior left lower leg is noted on deep palpation. Also, there is decreased two-point discrimination. What is the definitive treatment for this patient?

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A patient presents with right lower leg pain after a collision on the soccer field. The patient's left leg is warm to the touch, and he has excruciating pain with passive movement. Which of the following fractures is the highest risk of causing a similar pathology to what the patient is currently experiencing?

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A 28-year old new diabetic type 2 slightly overweight male had started an exercise program because of hyperlipidemia on day one and two he jogged 2 miles, but the third day, he had pain in the left lower leg. Even after stopping, he had pain at rest and found it difficult to walk. He presented to the emergency department where it was noted that the entire left leg was tense and he had pain on palpation along the anterior and lateral aspect of the lower leg. He was not able to plantarflex or dorsiflex his ankle because of pain. Emergency surgery was performed to treat his leg. One week later he comes to your clinic with left-sided foot drop and numbness in some areas of the left leg. What do you think should have been done to avoid this complication?

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A 16-year old slightly overweight male has decided to start an exercise program because of hyperlipidemia and a new diagnosis of type 2 diabetes. He starts to jog 2 miles every day, but after the third day, he develops pain in the left lower leg. Even after stopping he has pain at rest and now finds it even difficult to walk. In the emergency department, the left leg is very tense, appears wood-like, has numerous blisters, is pale and the patient is unable to flex or extend the ankle without pain. Which of the following labs would be most helpful in the diagnosis and management of this patient?

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A 30-year old, slightly overweight male has decided to start an exercise program because of hypertension and hyperlipidemia. He starts to jog 2 miles each day, but after the fifth day, he develops pain in the left lower leg. He has pain at rest and pain while walking. In the emergency department, it is noted that the left lower leg is tense, pale, very firm, and wood-like, and the patient has pain moving the ankle. If he is suspected of having an acute compartment syndrome, what maneuver may he benefit from?

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A 29-year old is jogging up a steep hill in the woods. He suddenly trips and falls 60 feet down a ravine. He is in intense pain and unable to sit up. The paramedics arrive, and he is transported to the nearest emergency department. Physical examination reveals that he has an open fracture of the right tibia. What is his risk of acute compartment syndrome with such an injury?

It is not a concern because open fractures lead to immediate decompression

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A 28-year old slightly overweight male is status postoperative day 1 from an open reduction and internal fixation of a right proximal tibial fracture. During the official handoff to the night-float team, the resident emphasizes the possibility of acute compartment syndrome in this patient. Which of the following objective finding on the physical exam should the night-float resident be aware of early on to suspect the concerned adverse event?

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A 28-year old slightly overweight male has decided to start an exercise program because of hyperlipidemia and a new diagnosis of diabetes mellitus type 2. He starts to jog 2 miles a day but after the third day, he develops pain in the left lower leg. Even after stopping he has pain at rest and now finds it even difficult to walk. He presents to the emergency room where you note that the entire left leg is tense and he has pain on palpation along the anterior lower leg. He is not able to plantar or dorsiflex his ankle because of pain. What is the most common cause of this pathology?

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A female was positioned in the dorsal lithotomy position and underwent a hysterectomy which was marred by bleeding and adhesions. The duration of the surgery was 6 hours and because of the patient's age and co-morbidity she was extubated and monitored in the intensive care unit. Within 6 hours of surgery, she complained of her right leg pain. Her blood pressure was 95/65 mmHg, pulse 110 bpm, respiratory rate 18, and temperature 98.7 F. The leg did not show any ecchymosis but was slightly swollen. Blood work revealed a potassium of 5.9 mmol/L, creatinine of 2.2 mg/dL, WBC 14 10^9/L, hemoglobin 8 g/dL, sodium 133 mmol/L, chloride 90 mmol/L, BUN 22 mg/dL, blood glucose 95 mg/dl, creatine kinase of 33,000 units/L and myoglobinuria. What is the next step in her management?

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A 17-year-old girl presents to the emergency department a few hours after playing a game of lacrosse. She is complaining of severe constant pain in her left thigh. She remembers jumping into the air to catch the ball and upon landing experienced acute pain in her left thigh but she continued playing. The examination shows that the left thigh is 42 cm in circumference compared with 35 cm on the right side. She has elevated interstitial pressure in the anterior compartment. What is the diagnosis?

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A young male presents to the emergency department complaining that the cast applied to his right leg is too tight and his leg is excruciatingly painful. The cast was placed in the operating room 1 day ago following a fracture. Examination suggests he may have acute compartment syndrome. What workup is usually done in such cases? Select all that apply.

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A nurse is rounding in the medical-surgical unit after receiving shift report from a team member. One of her patients, who was admitted from the emergency department with a fractured radius and ulna, asks for pain medication. The nurse checks the medication administration record for an as needed order and realizes the patient had hydromorphone 1 mg IV push 30 minutes ago. The patient suffered a crush injury about after a golf cart rolled over and pinned him underneath. The right upper extremity has a fiberglass splint in place. Neurovascular assessment reveals a grossly swollen, tense, cold, pale, extremity with capillary refill greater than 2 seconds. A pulse is present with a Doppler device. The patient reports a pain level of a 9/10. The pain worsens on passive motion, and two-point discrimination is decreased. Based on the assessment data obtained, how does the nurse proceed in the care of this patient? Select all that apply.

Notify the licensed healthcare provider in charge of the care of the patient immediately

Administer additional as needed medication ordered for breakthrough pain and reassess the patient in an hour

Loosen up the elastic wrap around the fiberglass splint

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A 17-year-old female sustains a circumferential burn of the left forearm in a campfire accident, with additional burned areas along the left side of her body. There was no significant impact. While assessing her total body surface area affected and evaluating her need for formal fluid resuscitation, she states that her left hand is developing “excruciating, deep, achy” pain. Initial inspection is normal. The radial or ulnar pulses on the left wrist are not palpable. Upon touching the patient’s hand she screams in agony, and the posterior forearm is taut to palpation. What are the likely diagnosis and the next best step in management of this patient?

This is likely compartment syndrome of the extremity. Proceed with fluid management before addressing the extremity

This is likely compartment syndrome of the extremity. Escharotomy is indicated before fluid resuscitation begins

This is likely a developing hematoma from the burn. Warm and cool compresses should be initiated after fluids are started

This is likely an occult fracture secondary to the inflammation caused by the burns. The forearm needs to be splinted after fluids are started

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A 76-year-old man complains of severe left calf pain 6 hours after undergoing a left femoral artery embolectomy. He complains of pain on the upper posterior aspect of his left calf that is burning in nature. On physical exam, his blood pressure is 155/80 mmHg, and heart rate is 110/min and regular. His left calf is swollen, tense and exquisitely tender. Pain is worsened with passive extension of the left knee. Peripheral pulses are palpable, intact and equal. Surgical wounds are well-appearing, with scant serosanguineous drainage. Which of the following is the most likely cause of the patient's current symptoms?

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A 74-year-old man presents with a complaint of extreme pain in his left leg. He underwent popliteal artery stenting four hours ago for severe peripheral vascular disease of the left leg. Physical exam reveals a cool, pale left leg, and pain out of proportion to the physical exam. What diagnostic value is pathognomonic for this patient's condition?

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A 26-year-old patient just had surgery for a both-bone forearm fracture. Adequate alignment was obtained, a posterior splint was applied by postoperatively, and the immediate postoperative course was uncomplicated. On the floor, the patient starts complaining of numbness and moderate pain around his forearm. The immediate first step in the management of this patient is which of the following?

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A 30-year-old male mechanic presents to emergency department 12-hours after having his forearm run over by a car. His blood pressure is 130/90 mm Hg, and heart rate is 110 bpm. Radiographs show no fractures or osseous abnormalities. His forearm is very swollen but soft and compressible. A stryker monitor was used which showed intra-compartmental pressures of 35 mm Hg. The patient does not have pain with passive extension of his fingers or wrist. Which of the following is the next best step in management for this patient?

Ice and elevation with serial clinical compartment checks in the hospital

Soft compression bandage application, discharge home with instructions to ice and elevate once the patient is comfortable

Repeat stryker monitoring in 1 hour

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A patient presents with a forearm crush injury. The forearm is swollen, and the clinician measures the pressures for the volar and dorsal compartments which are both under 30, while diastolic pressure is 70. The patient has significant pain with any wrist movement and his forearm is moderately tense. Which of the following is true?

The patient does not have compartment syndrome based on the readings on the stryker monitor

The patient should undergo compartment releases in the operating room

The patient should be iced and elevated, along with, repeat volar and dorsal compartment pressure measurements in 1 to 2 hours

An MRI should be obtained to assess for occult fractures missed on initial radiographs

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An 18-year-old football player presents to the emergency department with what appears to be a lower leg deformity after being tackled to the ground. His heart rate is 70 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 120/80 mmHg. Physical exam reveals a swollen and tense left lower extremity with numbness in the first webspace adjacent to his hallux. The patient also is identified to have a loss of two-point discrimination on a sensory exam, severe pain on passive dorsiflexion but has retained pulses. X-ray reveals a comminuted displaced tibial plateau fracture. Which of the following is the most appropriate management of this patient's condition?

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A 27-year-old male presents to the emergency department after being struck by a car while riding his motorcycle with what appears to be a lower leg deformity. His heart rate is 90 beats per minute, respiratory rate 20 breaths per minute, and blood pressure is 134/80 mmHg. The physical exam reveals a swollen and tense left lower extremity. The patient also is identified to have a loss of two-point discrimination on the sensory exam, severe pain on passive dorsiflexion but has retained pulses. X-ray reveals a comminuted displaced tibial plateau and mid-shaft fibula fracture. The patient is found to have an acute compartment syndrome of his lower leg and is emergently brought to the operating room for a fasciotomy. The surgeon extends the lateral fasciotomy incision too far up and over the fibular head. What is the expected deficit if the nerve in this region is injured?

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A 22-year-old male is accidentally run over by a dump truck at a construction site. The patient's lower leg is crushed, and he is brought into the emergency department. He is found to have an acute lower extremity compartment syndrome from a tibia and fibula fracture and is brought to the operating room for a two-incision, four-compartment fasciotomy, and external fixator placement. The patient thereafter is admitted to the intensive care unit for close observation and neurovascular checks of his lower extremity. The following morning the patient complains of worsening pain in his leg and new numbness developing in the first webspace of his toes. The patient's lab work shows a white blood cell count of 14,000/microL, creatine kinase 20,000 units/L, potassium 5.4 mmol/L, creatinine 1.8 mg/dL, lactic acid 3.5 mmol/L and urinalysis with large blood and no red cells detected. The patient's creatine kinase on admission was 4,000 units/L, creatinine 0.9 mg/dL, and lactic acid 2.2 mmol/L. Which of the following is the most likely cause of the patient's current condition?

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Brandão RA,St John JM,Langan TM,Schneekloth BJ,Burns PR, Acute Compartment Syndrome of the Foot Due To Frostbite: Literature Review and Case Report. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2018 Mar - Apr [PubMed]

Meulekamp MZ,Sauter W,Buitenhuis M,Mert A,van der Wurff P, Short-Term Results of a Rehabilitation Program for Service Members With Lower Leg Pain and the Evaluation of Patient Characteristics. Military medicine. 2016 Sep [PubMed]

McQueen MM,Gaston P,Court-Brown CM, Acute compartment syndrome. Who is at risk? The Journal of bone and joint surgery. British volume. 2000 Mar; [PubMed]

McQueen MM,Duckworth AD, The diagnosis of acute compartment syndrome: a review. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2014 Oct; [PubMed]

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